Trends in the surgical management of Klatskin tumours

Role of dual-time point 18F-FDG PET/CT imaging in the primary diagnosis and staging of hilar cholangiocarcinoma

PURPOSE

The aim of this study was to evaluate the role of dual-time point ¹⁸F-FDG PET/CT imaging in the primary diagnosis and staging of hilar cholangiocarcinoma (HCCA).

METHODS

Dual-time point FDG PET/CT findings, including early phase whole-body scanning and abdominal delayed phased performed 1 and 2 h after radiotracer injection, respectively, were retrospective reviewed in 69 patients conformed HCCA by histology. PET/CT was evaluated based on visual interpretation and the semiquantitative index of SUVmax and tumor-to-normal liver tissue ratio (TNR) for both early and delayed images.

RESULTS

For all 69 HCCA patients, the mean SUVmax of the lesion and TNR in delayed phase was significantly higher than that in early phase (6.1 ± 4.7, 2.2 ± 1.7, vs 5.1 ± 3.4, 1.6 ± 1.1; P < 0.001). The sensitivity and accuracy value of detection primary lesions was 69.6% and 70% in early phase vs 76.8% and 76.8% in delay phase, respectively. There was a significant correlation between lesion SUVmax and Ki67 index in both dual-time imaging (r = 0.462, P < 0.001 in early phase vs r = 0.47, P < 0.001 in delay phase). The sensitivity, specificity and accuracy value of metastatic lymph nodes prediction was 50%, 67.3% and 71% in early phase vs 62.5%, 73.3% and 76.8% in delayed phase, respectively. The sensitivity, specificity and accuracy of FDG PET/CT in detecting distant metastasis in our study was 75%, 100% and 97.1%. There was no difference of predicting distant metastasis between early phase and delayed phase.

CONCLUSION

Delayed phase in dual-time point ¹⁸F-FDG PET/CT scan provides additional usefulness for detection primary tumor and lymph nodes metastases in HCCA, but there was no added benefit of delayed PET/CT imaging in detection of distant metastases in this study. SUVmax in early and delayed phase could be used to assess tumor aggressiveness in pre-treatment HCCA.

Differentiation of intraductal growing-type cholangiocarcinomas from nodular-type cholangiocarcinomas at biliary MR imaging with MR cholangiography

PURPOSE

To describe the magnetic resonance (MR) findings of intraductal growing (IDG)-type cholangiocarcinoma (CC) and to identify the features that differentiate it from nodular-type CC.

MATERIALS AND METHODS

The institutional review board approved this retrospective study and waived the informed consent requirement. Thirty-nine patients with pathologically proved IDG-type (n = 19) or nodular-type (n = 20) CCs who had undergone preoperative gadolinium-enhanced MR imaging with MR cholangiography were included in this study. Analysis of MR findings included determination of the (a) shape, enhancement degree, and pattern of the tumor; (b) outer caliber of the tumor-bearing segment; and (c) presence of tumor multiplicity, upstream and downstream bile duct dilatation, bile duct wall thickening adjacent to the tumor, and adjacent organ invasion. The significance of these findings was determined with the χ² test.

RESULTS

Significant features in the differentiation of IDG-type CCs from nodular-type CCs included papillary or irregular polypoid shape, lack of constriction of the tumor-bearing segment, hypoenhancement of the tumor to the liver during the equilibrium phase, tumor multiplicity, upstream and downstream bile duct dilatation, and no bile duct wall thickening adjacent to the tumor (P < .05). When at least two of these six imaging features were used in combination, sensitivity and specificity in the diagnosis of IDG-type CCs were 95% and 70%, respectively.

CONCLUSION

By using characteristic MR features, one can differentiate IDG-type CC from nodular-type CC with a high degree of accuracy at biliary MR imaging with MR cholangiography.

Gadobutrol-enhanced, three-dimensional, dynamic MR imaging with MR cholangiography for the preoperative evaluation of bile duct cancer

PURPOSE

To evaluate the diagnostic performance of 1.0-M gadobutrol-enhanced, 3-dimensional (3D), dynamic MR images with 3D-MR cholangiography (MRC) in the preoperative evaluation of bile duct cancer staging and resectability.

MATERIALS AND METHODS

Our institutional review board approved this retrospective study. Sixty patients (46 male, 14 female; mean age 65.9 years; range, 45-77 years) with surgically and pathologically proven bile duct cancers, were included in this study. Two gastrointestinal radiologists evaluated the biliary MR images, including 3D-MRC and gadobutrol-enhanced, dynamic images, using a 3D-gradient echo (GRE) technique, regarding the longitudinal tumor extent, vascular involvement of the bile duct cancer, lymph node metastasis, and tumor resectability. The results were compared with the surgical and pathology findings used as the reference standards.

RESULTS

The area under the receiver operating characteristic curve (Az) of the 2 reviewers was 0.95 and 0.93, respectively, for evaluation of the involvement of both secondary biliary confluences and 0.85 and 0.84, respectively, for assessment of the intrapancreatic duct. For determining the tumor resectability, the overall accuracy was 0.93 and 0.88, respectively, whereas for assessment of the vascular involvement, the Az values were 0.92 for reviewer 1 and 0.70 for reviewer 2 for the portal vein evaluation, and 0.99 for reviewer 1 and 0.76 for reviewer 2 for the hepatic artery evaluation. In the assessment of lymph node metastasis, the overall accuracy was approximately 0.77 for each reviewer.

CONCLUSION

One-molar, gadobutrol-enhanced, dynamic imaging, using a 3D-GRE technique with isotropic 3D-MRC showed excellent diagnostic capability for assessing the longitudinal extent and tumor resectability of bile duct cancer, although it generally underestimated the tumor involvement of vessels and lymph nodes.

Application of Portal Parenchyma–Enterostomy after High Hilar Resection for Bismuth Type IV Hilar Cholangiocarcinoma

For the surgical treatment of Bismuth Type IV hilar cholangiocarcinoma, it is difficult to achieve curative resection (R0 resection) with restrictive excision (local resection and parenchyma-preserving liver resection) as a result of the complexity and difficulty in biliary reconstruction. Extended hepatectomy with vessel resection can improve the rate of curative resection, but it can also give rise to postoperative complications and mortality. We proposed a high hilar resection and portal parenchyma–enterostomy method to improve the surgical procedure. Eleven patients with Bismuth IV hilar cholangiocarcinoma underwent high hilar resection (resection for tumors in bile ducts and 1 cm above the tumors including segments IVb, V, and part of the caudate liver lobe) and the biliary tract was reconstructed through a portal parenchyma–enterostomy. Biliary radicles were not ligated but were drained into the “bile lake.” No cases of perioperative death were observed. Four weeks after surgery, patients’ serum aspartate aminotransferase, alanine aminotransferase, and total bilirubin were decreased evidently. The average survival was 25.3 months. In conclusion, the portal parenchyma–enterostomy procedure can be performed with increased curative rate and reduced parenchyma resection, extending the survival time of patients and improving patients’ quality of life.

Changes in the surgical approach to hilar cholangiocarcinoma during an 18-year period in a Western single center

BACKGROUND

Liver resection is the only potential curative treatment for hilar cholangiocarcinoma. In this article, we evaluate mortality, survival, prognostic factors, and changes in surgical approach during the last two decades at a Western hepato-biliary center.

METHODS

Fifty-one patients undergoing liver resections constitute the study population. Patients undergoing palliative procedures were considered as a control group for comparison to the resected group. After 1997, a more aggressive surgical approach was applied that is based on the experience of Japanese surgeons.

RESULTS

Curative resections were achieved in 37 (72.5%) patients, and R1 resections were performed in 14 (27.5%). The overall 3- and 5-year survival rates were 47.3 and 34.1%, respectively. The 3- and 5-year survival rates were 38 and 19% in the R1 resection group, and 15% and 0 in the non-resected group, respectively. Univariate analysis revealed that lymph node and perineural invasion, R1 resection, and a bilirubin level >10 mg/dl affected long-term survival. Multivariate analysis showed that only perineural invasion was significant in affecting long-term survival. Univariate analysis showed that the mean preoperative bilirubin levels and mean blood transfusion were related to the mortality rate. The resectability rate significantly increased from 25 to 75.6% after 1997 following implementation of the new surgical approach.

CONCLUSIONS

An aggressive surgical approach increases the resectability rate and may improve long-term survival even after R1 resection. Severe hyperbilirubinemia should be preoperatively drained, possibly by the percutaneous approach.

MR imaging and MR cholangiopancreatography in the preoperative evaluation of hilar cholangiocarcinoma: correlation with surgical and pathologic findings

The primary aim was to evaluate delayed contrast-enhanced MRI in depicting perineural spread of hilar cholangiocarcinoma (CCC) and consequently to determine the capability of MRI/MRCP for staging CCC. Fifteen patients that underwent MRI/MRCP and surgical treatment were retrospectively included. Two radiologists evaluated MR images to assess delayed periductal enhancement, extent of bile duct stenosis, liver parenchymal and vascular involvement and presence of liver atrophy. An agreement between delayed enhancement of the bile duct walls and perineural neoplastic spread showed a very good correlation factor (0.93). The overall accuracy in detecting biliary neoplastic invasion was higher for delayed T1-weighted images (93.3%) than for the MRCP images (80%), and T1-delayed image increased the MR accuracy in assessing the neoplastic resectability (p<0.05). MRI correctly predicted vascular involvement in 73% and liver involvement in 80% of the cases. The number of overall correctly assessed patients with regard to resectability was 11 true positive, 1 false positive and 3 true negative. The combination of MRI/MRCP is a reliable diagnostic method for staging hilar cholangiocarcinomas. Delayed periductal enhancement is accurate in the evaluation of neoplastic perineural spread, and it can improve diagnostic accuracy to identify resectable and unresectable tumours.

A new technique of biliary reconstruction after "high hilar resection" of hilar cholangiocarcinoma with tumor extension to secondary and tertiary biliary radicals

BACKGROUND

Radical operation for hilar cholangiocellular carcinoma, including extended hepatic resection, seems to improve prognosis by increasing the surgical curability rate. Nevertheless, high postoperative morbidity and mortality have been reported in patients with obstructive jaundice. We describe the technique of "high hilar resection" and a modification of bilioenteric anastomosis for drainage of the multiple secondary or tertiary biliary radicals.

METHODS

Ten patients with advanced hilar cholangiocellular carcinoma underwent a high hilar resection with complete parenchymal preservation, and the biliary drainage was reconstructed by a sheath-to-enteric hepaticojejunostomy. Because of the technical difficulty caused by anastomosis line in the range of the biliary sheath, a modification was performed by dividing the biliary apertures of segments 5 and 4b.

RESULTS

A high hilar resection was successfully performed, and all patients were discharged from the hospital in good condition. No patient died postoperatively. The proximal resection margin was tumor-free in all patients. One patient died after 29 months of peritoneal carcinomatosis. None of the patients developed local recurrence around the hepaticojejunostomy. The remaining nine patients are alive after a mean follow-up of 28.8 months after surgery without any signs of recurrence.

CONCLUSION

In highly selected patients with advanced hilar cholangiocellular carcinoma, a high hilar resection is technically safe and oncologically justifiable. In combination with our new technique of sheath-to-enteric anastomosis, the patients considerably benefit from the preservation of liver parenchyma with low postoperative morbidity and very short in-hospital stay.